Field RN Case Manager/Sun-Wed Cornerstone Hospice
About The Position
The RN, Care Coordinator assesses and identifies patient and family needs, uses the nursing process, coordinates the Plan of Care with the Interdisciplinary Group (IDG), and provides palliative and supportive care to the patient and family. The role provides and manages direct patient and family care as part of the Interdisciplinary Team (IDT), integrating psychosocial, spiritual, cultural, physical, and biological considerations with appropriate nursing interventions and follow-up. The nurse develops and coordinates an individualized Plan of Care that reflects changing patient needs; educates patients, families, caregivers, and other health professionals; reports changes in condition; and participates in evaluating hospice referrals and admissions for appropriate levels of care. Home visits may assess safety, medication and nutritional compliance, durable medical equipment (DME) compliance, and the patient’s ability to live safely in the community. Visit frequency depends on risk score and needs. The position communicates and collaborates with physicians, IDT members, facilities, patients, and families, and may supervise care delivered by Community Health Workers and Home Health Aides when requested. During emergencies, the RN Case Manager may need to report to a company-designated location ahead of schedule and stay overnight to maintain continuity of services.
Requirements
- Current RN license in the state where the employee will work.
- At least one year of nursing experience; hospice or hospital experience is preferred.
- Previous experience working with an EMR/EHR system.
- Valid driver’s license and automobile insurance in accordance with company policy.
- Reliable transportation to meet the visit schedule.
- Ability to use equipment with visual and auditory mechanisms.
- Ability to communicate effectively in English, verbally and in writing.
- Ability to visit participants in their homes to conduct assessments.
- Ability to perform the essential job functions and physical requirements, with or without reasonable accommodation.
- Active BLS for healthcare professionals from the American Heart Association or Red Cross.
- For employees working at PACE: completion certification for Alzheimer’s Disease and Related Dementias Training through the Florida Department of Elder Affairs.
- Satisfactory completion of the position’s competency requirements.
- Consent to drug and/or alcohol testing after a conditional offer and ongoing compliance with the Drug-Free Workplace Policy.
- For employees providing services for Florida affiliates: eligibility verification through the Florida Care Provider Background Screening Clearinghouse after a conditional offer, with ongoing eligibility.
Nice To Haves
- Hospice or hospital nursing experience.
Responsibilities
- Assess and identify patient and family needs using the nursing process.
- Provide and manage direct care to patients and families as part of the Interdisciplinary Team, incorporating appropriate nursing interventions and follow-up.
- Coordinate the Plan of Care and ensure it is individualized and accurately reflects the patient’s evolving needs.
- Educate patients, families, caregivers, and other health professionals about disease progression, prevention, palliative interventions, caregiving, the dying process, and safety practices.
- Conduct home visits to assess home safety, medication compliance, nutritional compliance, DME compliance, and the patient’s ability to live safely in the community.
- Report changes in patient condition to appropriate IDT members and other health professionals.
- Participate with the IDT in evaluating hospice referrals and admissions for appropriate levels of care.
- Attend daily IDT collaboration meetings and present concise, pertinent oral and written reports while encouraging input from all disciplines.
- Communicate accurately and completely with physicians, staff, patients, families, and supervisors, using timely clinical communication such as SBAR.
- Supervise patient care provided by Community Health Workers and Home Health Aides when requested.
- During emergencies, report to a company-designated location as required, potentially ahead of schedule and overnight, to ensure continuity of services.
- Perform other duties as assigned.
- Some locations may require providing phone reassurance to patients and families, helping resolve questions or identifying the need for an in-person visit, and coordinating visits when needed or requested.
- Some locations may require using appropriate support resources to resolve complex situations, documenting patient and family contacts in the EMR, completing initial and semi-annual assessments, explaining services, initiating plans of care and skilled nursing interventions, obtaining physician orders, completing documentation, representing the company at assigned facilities, facilitating referrals, discussing potential needs with after-hours staff, and developing relationships with facility case managers and physicians.
- Represent the company professionally; comply with applicable regulations and company policies; maintain confidentiality; observe health, safety, and security practices; use resources responsibly; participate in community and professional organizations, performance improvement, quality activities, research, and education; maintain professional knowledge and electronic media skills; and share expertise with coworkers.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
